Put Your Money on Safety

Kate Kelly, PharmD, and Allen J. Vaida, PharmD, FASHP

Published Online: Sunday, August 1, 2004

Follow Pharmacy_Times:

Problem

We here at the Institute for Safe Medication
Practices often hear about
strategies that are employed to reduce
medication expenditures for patients or
organizations. Although many of these
strategies are quite effective at saving
money while enhancing or preserving
patient safety, some may actually work
to compromise patient safety along the
way. For example, one rheumatologist's
common practice of prescribing injectable
methotrexate for oral administration
nearly led to serious harm. This
unusual use of an injectable product
was initiated to save his patients
money, because the injectable product
is much cheaper than the tablets on a
per-milligram basis.

When one of the rheumatologist's
patients was hospitalized, however,
the patient's wife told a nurse practitioner
that her husband took 80 cc of
methotrexate injection weekly. The
nurse practitioner subsequently ordered
"methotrexate injection 80 cc
every Sunday." Actually, the patient
had been prescribed 0.8 mL (20 mg) of
injectable methotrexate weekly, as an
oral dose. The patient's community
pharmacist had dispensed the drug
with insulin syringes and told the
patient to draw up 80 units, mix the
medication with orange juice, and
then drink it. The patient's wife confused
units with cc when stating the
volume of medication that her husband
took. It is not clear whether the
patient was given insulin syringes
because he was already familiar with
them, or whether the pharmacy did
not carry tuberculin syringes. An oral
syringe would have been more appropriate
for the dosing regimen, but it
does not permit the withdrawal of
solution from an injectable vial. Confusion
between units and cc might
have been avoided if the patient had
been using a tuberculin syringe to
draw up his medication (although, in
this case, we do not recommend using
the injectable product orally).

Because the concentration of the
injectable methotrexate was 25
mg/mL, the nurse practitioner's order
could have led to a 2 g overdose. To
make matters worse, the nurse caring
for the patient did not realize that the
injectable product was supposed to be
given orally! Fortunately, a hospital
pharmacist noticed the error and
averted a potentially fatal case of
myelosuppression.

In another cost-versus-care example,
officials at an ambulatory clinic made a
decision to offer free emergency contraception
(EC). Because this was a free
service, the clinic personnel looked for
the most cost-effective treatment regimen.
They decided to use Ovral
(norgestrel/ethinyl estradiol) instead of
Plan B (levonorgestrel) due to a significant
cost savings. (The per-patient treatment
cost of Ovral is about half that of
Plan B.) Ovral is packaged in 21- and 28-day
blister packs intended for ongoing
use in preventing pregnancy. When
used for EC, patients take 2 Ovral tablets
within 72 hours of unprotected intercourse
or known or suspected contraceptive
failure. This dosage is followed
by an additional 2 tablets 12 hours after
the first dose. Plan B is specially packaged
and labeled for individual use in
EC. Patients take 1 tablet within 72
hours of unprotected intercourse or
known or suspected contraceptive failure,
followed by 1 tablet 12 hours later.

The clinic protocol for EC was for the
nurse practitioner to dispense 4 Ovral
tablets and to instruct the patient to take
2 tablets immediately and 2 tablets in 12
hours. In this instance, the nurse practitioner,
possibly familiar with the 2-tablet
dosing regimen of Plan B, dispensed
only 2 Ovral tablets. The error was discovered
5 weeks later, when the patient
had a positive pregnancy test. When
questioned about the medication, the
patient reported that she had received 2
tablets at her previous visit. The patient
was informed of the error and decided to
continue with the pregnancy. The clinic
personnel reported that they would look
into getting a prepackaged, ready-to-use
form of EC in order to prevent similar
errors from occurring.

Safe Practice Recommendations

Although affordability is an ever-present
issue that affects access to medications,
health care practitioners must
carefully weigh affordability against
patient safety issues when cost-saving
measures are employed. When medications
are dosed or used in an unconventional
manner in an effort to contain
costs (yet another example would
be tablet splitting), health care practitioners
should consider the following:

Before implementing any new
cost-saving strategy, proactively
consider the types of errors that
could occur as a result of this strategy.
For example, consider the
risks/difficulty involved with an
arthritic patient manipulating a
syringe to draw up an injectable
product in order to take it orally.

Identify the potential risks associated
with using the medication in
this manner, and determine
whether the risk justifies the cost
savings. The person who reported
the methotrexate error above
noted that her hospital has recognized
the practice of using an
injectable product for oral use as
error-prone. So, to minimize the
risk of error, the hospital's policy
no longer permits the oral use of
injectable methotrexate.

Verify the patient's medication
history, using sources other than
the patient or family members, if these sources are
not reliable; if the information provided seems
unusual; or if the appropriateness of the dosing regimen
is questionable.

If it is decided that the cost savings justify the use of
the medication in an unconventional manner,
employ methods to minimize any risks. For example,
in the case above, the clinic could prepackage 4 Ovral
tablets in ready-to-use kits that include an explanation
as to how to take the medication properly.

Whenever possible, involve a pharmacist in the dispensing
process. The EC error might have been averted
if a pharmacist had been involved. Clarify any
order that is incomplete. It is dangerous to write or
accept orders without a route of administration or
with only a volumetric dose (eg, "methotrexate injection
80 cc every Sunday"), even if the product is
available in a single concentration or by a single
route.

Educate patients, caregivers, and involved practitioners
that the medication is being used in an unconventional
manner. Counsel patients regarding how to use the
medication, as well as about the potential risks involved
with using the medication in such a way.

Drs. Kelly and Vaida are both with the
Institute for Safe Medication Practices
(ISMP). Dr. Kelly is the editor of ISMP
Medication Safety Alert! Community/
Ambulatory Care Edition, and Dr. Vaida
is the executive director of ISMP.

Report Medication Errors

The reports described here were received through the USP
Medication Errors Reporting Program, which is presented in
cooperation with the Institute for Safe Medication Practices
(ISMP). ISMP is a nonprofit organization whose mission is to
understand the causes of medication errors and to provide time-critical
error-reduction strategies to the health care community,
policy makers, and the public. Throughout this series, the underlying
system causes of medication errors will be presented to
help readers identify system changes that can strengthen the
safety of their operation.

If you have encountered medication errors and would like to
report them, you may call ISMP at 800-324-5723(800-FAILSAFE)
or USP at 800-233-7767 (800-23-ERROR). ISMP's Web
address is www.ismp.org.

Subscribe to Newsletter

Pharmacy Times and the Institute for Safe Medication
Practices (ISMP) would like to make community pharmacy
practitioners aware of a publication that is available.
The ISMP Medication Safety Alert! Community/Ambulatory
Care Edition is a monthly compilation of medication-related
incidents, error-prevention recommendations, news,
and editorial content designed to inform and alert community
pharmacy practitioners to potentially hazardous situations
that may affect patient safety. Individual subscription
prices are $45 per year for 12 monthly issues. Discounts
are available for organizations with multiple pharmacy
sites. This newsletter is delivered electronically. For more
information, contact ISMP at 215-947-7797, or send an email
message to community@ismp.org.